1.  64 YOM with pmhx notable for
CHF/CAD presents with 3 days  T 98.7 P 110 BP 180/80
worsening dyspnea with exertion. O2 92% (ra), RR 22
He can usually easily walk from room
to room in his home however in the
last three days he has been unable to  Gen: WDWN, anxious
cross a room without stopping to
catch his breath. The patient denies  CV: Tachycardic, RR,
outright chest pain/ diaphoresis any
recent cough/congestion, fevers or cr<3 sec.
chills. This episode is reminiscent of
his “heart failure acting up” He has  Pulm: Lungs show poor
been using his medications as
prescribed. At presentation he has air movement with rales
mild increased work of breathing; he
is speaking in 5-7 word sentence
from the mid lung
fragments. He is awake/alert. fields to the bases
bilaterally.
 Abd: s/nt/nd
 Ext: no cy/cl/ed

3. Note mild interstitial pulmonary edema in a patient with likely poorly controlled
hypertension and hypertensive cardiomyopathy.
PA/Lateral films show signs of interstitial pulmonary edema (increased interstitial
markings).
Lateral radiograph—Thickened interlobar fissures (subpleural edema) (12B,
black arrowheads),

4.  Pulmonary
 100% O2 by face mask should be administered to achieve O2
saturation of >94% by pulse oximetry.
 If hypoxia persists despite O2 therapy: apply biphasic positive
airway pressure via face mask.
 Unconscious or visibly tiring patients should be intubated.

5.  Cardiac
 Nitroglycerin should be administered 0.4 mg sublingually (may be
repeated q1–5 minutes) or as a topical paste in 1–2 in. If no response
or ECG shows ischemia, NTG 10 mcg/min should be initiated as an
IV drip and titrated to BP and symptomatic improvement
 For hypotensive patients or patients in need of additional inotropic
support start dopamine 5–10 mcg/kg/min and titrate to systolic BP
of 90–100 mm Hg
 When indicated administer a potent IV diuretic, such as furosemide
40–80 mg IV

6.  Medical management
 For patients with resistant hypertension or those who are not
responding well to NTG: nitroprusside may be used, starting at 2.5
mcg/kg/min and titrated.
 In the setting of ESRD the definitive treatment of pulmonary edema
is volume management with dialysis.
 Etiology
 Until excluded, AMI should be considered as the cause of
exacerbation.
 Acute mitral valve or aortic valve regurgitation should be
considered, especially if the heart is of normal size, because the
patient may need emergency surgery.

7. Septal lines Septal lines
(Kerley B lines) (Kerley B lines)
were present later resolved
initially. after diuresis

8. -Blurred vascular margins and Blurred vascular margins and
distension of upper zone blood cephalization later resolved
vessels (Cephalization). arrowheads arrowheads.
-Peribronchial cuffing (black arrow) Peribronchial cuffing also resolved
(white arrow).

9. Pulmonary edema resolved after several days treatment with diuretic medications.
Cardiac enlargement and hilar venous distension (upper zone vascular prominence) also
improved.
Lateral radiograph shows improvement of thickened interlobar fissures (subpleural
edema).